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Focus on Function

November 25, 2013

Filed under: Business of Dentistry,Philosophy — Tags: , , — Barry @ 1:18 PM

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When I speak I tell dentists that their patients come to them for four reasons: health, comfort, function and esthetics.  That’s today, but the profession has evolved into that position.  I am sure that the very first dental patient sought treatment for pain (comfort).  That particular type of patient probably dominated the dental landscape for the majority of history…at least before George Washington’s wooden teeth.

Modern times brought more and more patients seeking treatment for the other reasons listed above, but right through the days of Doc Holliday and Dodge City, and Painless Parker, the main reason was for relief of pain.  Then somewhere in the late 19th Century and early 20th Century, dentistry became legitimatized with the advent of the the American Dental Association and an organized system of dental education.  Dentists became doctors—and health and saving teeth was added to reasons people sought treatment.

But “health” is a vague term that means different things to different people.   To many it means keeping teeth for a lifetime.  Certainly a worthy goal, that requires quite a bit of attention to not only teeth but to gums as well as to bites.  My feeling is that too many dentists and even dental educators fail to describe what real health is.  But the focus on dentistry has been “health” for many years.


A new focus on cosmetics replaced comfort and health.  The “Cosmetic Revolution” started in the mid-nineties and it remains today as the focus of dentistry for many doctors and patients.  For other dentists it has become a distraction to the “health” issue and helping patients keep their teeth for their whole lives.

I agree that comfort, health and esthetics are very important goals for any dental practice—but as my practice evolved over the last forty years and my patients have gotten older, I have found a new perspective on the fourth reason…function.

Dental disease is chronic disease.  Not as life-mandating as heart disease, diabetes or cancer — but chronic, preventable disease, that if left alone will cause the body to break down and threaten quality of life and longevity.

Lately, I have been treating a significant number of nonagenarians (those lucky enough to reach the age of ninety).  For these patients, optimal health and esthetics take a back seat to loss of function.  It’s a whole new ballgame when these patients have to alter the way their bodies worked for so many years.

Even at my spry age of 66, the most important thing in my life is to wake up every morning and have everything working properly.  The old cliche’ about flossing only the teeth you want to keep, takes on new meaning when you look at it through the lens of function.

Norman Mailer wrote the Pulitzer Prize winning book, The Executioner’s Song, about serial killer Gary Gilmore.  Notably, the thing that Gilmore regretted more than anything was that he had no teeth to eat his last meal consisting of steak, potatoes, milk and coffee.  He only had the milk and coffee.

I hope I don’t sound too morbid, but I have learned to live better by trying to understand how I will make my final exit.

My elderly patients teach me that everyday. 

 In my book The Art of Case Presentation I refer to my friend Dr. Ken Myers of Portland Maine.  Some years ago he started his 80/20 Club.  In order to become a member, the patient had to be at least 80 years old and still have 20 natural teeth.  When I see photos of the club that they take at yearly luncheons, I am always impressed by how vibrant and happy they look.

Some years ago I read an excellent article by Dr. Atul Gawande, about frailty and the elderly.  Gawande, the author of The Checklist Manifesto is an excellent writer who has a very good handle on healthcare in America.  His philosophies have changed the way I think about health…and dental practice.

He describes frailty as a loss of function.  Some of it comes with natural aging…but some can be prevented…

with a focus on function.